Worker's Comp Quote NameEmail AddressPhone NumberHow many locations of premises do you have?123 or moreLocation of PremisesStreet AddressCityStateZip CodeStreet AddressCityStateZip CodeStreet AddressCityStateZip CodeStreet AddressCityStateZip CodeHow many payroll categories do you have?123 or morePayroll Category #1(*example: Counter Sales, Clerical, Driver, Warehouse, Outside Sales, Architect, Computer Programmer, etc.)LocationStateNumber of EmployeesShow owner/s to be included separatelyEstimated Total Payroll for this CategoryPayroll Category #2(*example: Counter Sales, Clerical, Driver, Warehouse, Outside Sales, Architect, Computer Programmer, etc.)LocationStateNumber of EmployeesShow owner/s to be included separatelyEstimated Total Payroll for this CategoryPayroll Category #3(*example: Counter Sales, Clerical, Driver, Warehouse, Outside Sales, Architect, Computer Programmer, etc.)LocationStateNumber of EmployeesShow owner/s to be included separatelyEstimated Total Payroll for this CategoryPayroll Category #4(*example: Counter Sales, Clerical, Driver, Warehouse, Outside Sales, Architect, Computer Programmer, etc.)LocationStateNumber of EmployeesShow owner/s to be included separatelyEstimated Total Payroll for this CategoryPayroll Category #5(*example: Counter Sales, Clerical, Driver, Warehouse, Outside Sales, Architect, Computer Programmer, etc.)LocationStateNumber of EmployeesShow owner/s to be included separatelyEstimated Total Payroll for this CategoryHow many Owners, Partners, Relatives or Officers to be included or excluded?123Remuneration to be included must be part of rating informationOwner, Partner, Relative or Officer #1First & Last NameTitle/Relationship% of OwnershipDutiesIf owner/executives does any operations other than clerical type, they must be classified as such.Include or ExcludeIncludeExcludeRemuneration(Payroll)Owner, Partner, Relative or Officer #1First & Last NameTitle/Relationship% of OwnershipDutiesIf owner/executives does any operations other than clerical type, they must be classified as such.Include or ExcludeIncludeExcludeRemuneration(Payroll)Owner, Partner, Relative or Officer #1First & Last NameTitle/Relationship% of OwnershipDutiesIf owner/executives does any operations other than clerical type, they must be classified as such.Include or ExcludeIncludeExcludeRemuneration(Payroll)Please explain all "Yes" responses in RemarksDo/Have past, present, discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous materials?YesNo(e.g. Landfills, waste, fuel tanks, etc.)Any work performed underground or above 15 feet?YesNoAny employees under 16 years of age?YesNo(include number in remarks)Do you provide an employee health plan?YesNoAny work preformed on barges, vessels, docks, or bridge over water?YesNoAny employees over 60 years of age?YesNoAny part-time employees?YesNoAny group transportation provided?YesNoDo employees travel out of state on business?YesNoMaintenance or janitorial duties?YesNoIf yes, describe in remarks.Any work preformed on or near water?YesNoAny roofing work ever preformed?YesNoIf yes, describe in remarks.Any seasonal employees?YesNoIs any exterior work preformed above 2 stories?YesNoExposure to chemicals of any kind?YesNoRemarksDo you currently have Workers' Compensation insurance?YesNoIf yes, please complete the following information.Workers' Compensation DetailsCurrent Insurance CompanyCurrent Policy NumberPolicy Expiration DateCurrent Annual PremiumUSDHow many claims have you had in the past 3 years?Claims HistoryDate (Month & Year)Type of ClaimMedicalLost WagesAmount PaidUSDDate (Month & Year)Type of ClaimMedicalLost WagesAmount PaidUSDDate (Month & Year)Type of ClaimMedicalLost WagesAmount PaidUSD Send Message